The exploding C-section rate in America

“They’re never faulted for doing a c-section,” said Faith Frieden, chief of obstetrics and gynecology at Englewood Hospital and Medical Center in New Jersey. “It’s never the wrong decision to do a c-section. No one’s ever going to say to them, ‘why were you so quick to do the cesarean section?’

“Usually what happens is, if anything goes wrong, then they’re questioned later on, ‘wouldn’t it have been better if you did the cesarean section a little sooner?’ ‘Why didn’t you do the c-section?’ ‘Wouldn’t that have been the easiest way to deliver this baby “” the less traumatic way to deliver this baby?'” Frieden explained.

The exploding C-section rate in America 23 comments

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Anonymous

If C-sections are a form of “defensive medicine” (and really, what action of a physician has Kevin NOT called defensive medicine), is it an effective one? Has it lowered the number of suits?

If not, why is it the fault of others that physicians are doing ineffective things to avoid a risk they can’t accurately quantify?

And rather than ask more physicians if it’s a good way to avoid liability, given their poor track record in determining these things, wouldn’t it be smarter to ask attorneys who represent plaintiffs, or the insurers?

Anonymous

What should the C-Section rate be?

Elliott

C-section reimbursement is higher.

Anonymous

“C-section reimbursement is higher.”

How typically hypocritical for a lawyer to blame it on the money…

Anonymous

No more hypocritical than a doctor saying it’s not.

So, what should the C-Section rate be if the current one is too high?

Anonymous

So docs can’t accurately quantify the risk of not doing a c-section nor the efect of doing more. So therefore they should do nothing?

Do you wear your seatbelt? Do you know the risk associated with not wearing it or the risk reduction in doing so? Are you aware of the increased risks associated with seatbelts? Can’t quote the numbers or cite a study? Then why wear one?

Have you studied the effect of looking both ways before crossing the street? Can you cite the risk of crossing without looking and the reduction in risk by doing so? No? Good. Stop looking.

The idea that given a lack of evidence reasonable people should stop doing rational things is ridiculous, unless you are part of the “no such thing as defensive medicine” lobby.

Being “careful” is rational behavior, even in the absence of solid evidence. Lowering the threshold for C-sections may not be effective at reducing suits, but it will result in less worry for the doc. Suits may not reduce, but suits for not doing a c-section soon enough probably will. Creative attorneys will find some other angle, but it may be more difficult (or not – it hasn’t been studied).

Anonymous

” So therefore they should do nothing?”

Who said that? What they shouldn’t do is advocate political changes based on their responses to perceived risks they can’t quantify or understand.

“The idea that given a lack of evidence reasonable people should stop doing rational things is ridiculous, unless you are part of the “no such thing as defensive medicine” lobby.”

You’ve begged the question. There’s no evidence it’s a rational response. It’s a claimed response to a risk which again, they can’t quantify or let you know what effect the solution has. Not to mention that there may be other factors for the “explosion”.

“Lowering the threshold for C-sections may not be effective at reducing suits, but it will result in less worry for the doc. “

So we should make public policy on the doc’s fears, regardless of their legitimacy?

“Suits may not reduce, but suits for not doing a c-section soon enough probably will.”

Have they? Most of Edwards’ trial work was a decade ago – so what’s the result?

You’ve misunderstood. There is similarly no evidence that looking both ways before crossing the street reduced bad outcomes (please cite a study) but you certainly aren’t suggesting that looking both ways is irrational, or are you?

Anonymous

Again, poor comparison. If I’m crossing the street, I know the danger will most likely come from cars coming both ways – so I know that my danger will be reduced if I check to see what’s coming.

However, physicians have no clue if they reduce their danger, because 1, they don’t know what act or omission typically results in a CP lawsuit, and 2, they have no idea what the likelihood of a lawsuit is if they do or don’t do a C-section. Unlike the person crossing the street, they lack the basic knowledge to assess the risk.

And again, if you claim the C-Section rate is artificially high because of fear of a lawsuit, what should it be?

Anonymous

This is purely logical question, not based on any kind of knowledge of risks of C-section or risk of not doing it from someone without any knowledge or opinion on the subject.

If a doctor can be sued for any poor outcome, wouldn’t it be logical to assume that a doctor can be sued fora) having a poor outcome when not doing a C-section when it can be shown in court (regardless of merit) that doing the C-section would’ve helped prevented the outcomeb) having a complication from C-section when it could be shown in court (again, we don’t know about the merit of each case) that it wasn’t indicated.

If this is the case, wouldn’t the risks of being sued mirror the risks of a bad outcome for the patient? If this is the case, how would doing a C-section in cases when it is not indicated (i.e. when risks of the procedure exceed risks of not doing it) for purely defensive reasons would result in reducing law suits?

Anonymous

What is the basic knowlege that a person crossing the street has?

Any answer cannot contain knowlege that a car is coming, becuase the crosser isn’t looking. The only knowlege is that they believe that if they know a car is coming, they can take action to avoid it.

Well, as a physician, I KNOW a lawsuit is coming. I just don’t know when. This knowlege affects my decisions, even without precise knowlege of the a priori risk, or the extent of risk reduction by taking whatever available action, just as the street crosser does not know precisely how much his or her risk is reduced by looking both ways (people who look also get hit).

This leads to several conclusions that might not otherwise be made. How many c-sections are done because labor was longer than the phsyicians comfort threshold? Why is it that reproducible “evidence” that the doctors actions reduce the risk of a suit are necessary in public debate, but no reproducible evidence that the doctor’s inaction causes a problem are needed to make it the basis of a lawsuit in a court of law? Why is the standard of proof/evidence/reason greater when discussing policy than it is at trial?

The notion that an action has to be “proven” to be effective to call it “defensive medicine” is a straw man. Peoples motives are what they are, whether you agree that they are helpful or not.

You can conclude that the c-section rate is approaching what it “should be”, rather than being inflated by the reactions of physicians to the threat of lawsuits. If that is so, the lawsuit rate should still be declining.

Anonymous

“Why is the standard of proof/evidence/reason greater when discussing policy than it is at trial?”

It’s not. One does not need to have expert testimony from another physician to make policy decisions. You do to even get to a jury at trial, and in many states, to even file the claim.

“The notion that an action has to be “proven” to be effective to call it “defensive medicine” is a straw man. “

Who is claiming that? Putting aside that “defensive medicine” is essentially whatever a physician wants to call it, the issue is not whether it is or is not, the issue is whether we should be making policy on irrational fear. ESPECIALLY when no one can tell us what the rate would be if this fear, rational or not, didn’t exist.

And no, as a physician you do not KNOW a lawsuit is coming. You may never be sued. What’s more, you have no idea WHY a lawsuit might come. It could be from a delivery, it could be from something else. You have no idea.

Anonymous

One does not need to have expert testimony from another physician to make policy decisions. You do to even get to a jury at trial, and in many states, to even file the claim.

You are making my point. At trial, you need “expert testimony” – one person’s opinion. But in this discussion, or to set policy, we need empiric statistical evidence – a large trial – whatever. You are dismissing any individual’s opinion as irrational. Clearly, one person’s testimony (mine, or pick any other physician’s on this board, or qualify some expert) is inadequate – until you get to the courtroom. Then it’s gospel.

Anonymous

And no, as a physician you do not KNOW a lawsuit is coming. You may never be sued.

25% of phsycians are sued anulally (When Good Doctors Get Sued, 2001). So its a pretty good bet that if you practice long wnough, you will get sued. Or as my mentors used to say, if you don’t get sued, you aren’t practicing medicine.

Street crossers may never get hit by a car, either.

Anonymous

the issue is whether we should be making policy on irrational fear

I didn’t know we were talking about global warming.

Anonymous

” You are dismissing any individual’s opinion as irrational.”

No, I’m really not. But when your opinion is based on unquantifiable terms and seeking an unquantifiable, or at least undeclared goal, don’t expect it to be immune from criticism.

And no, the expert’s word is not treated as gospel. I’ve never seen the attorney on the other side genuflect during cross examination. And you just need one person’s opinion to get the claim to the jury, and there’s even a vetting process for that. You need a lot more than that to win.

Anonymous

“Street crossers may never get hit by a car, either.”

They might not, but they can be sure it’s less likely if they look both ways. Can you say the same about performing C-sections? No.

And of course, we’re discussing this as if lawsuits were the only reason there are more. We have no idea if that’s the case. It might be convenience of the patient, it might be convenience of the physician, it might be that the physician gets paid more.

Anonymous

anon 8:02:

re “If not, why is it the fault of others that physicians are doing ineffective things to avoid a risk they can’t accurately quantify?”

That statement is akin to lawyers proving birth injury association with cerebral palsy even though no single peer-reviewed study has shown such an association. I am not saying it’s right but when a JD wheels in a CP child, he is not using the “science” card or the “best evidence” card, rather the “heartstring” card. I am sorry you are so ethically bankrupt that you can’t seethe issue.

Anonymous

“That statement is akin to lawyers proving birth injury association with cerebral palsy even though no single peer-reviewed study has shown such an association.”

Are you saying that there is literally no proof that oxygen deprivation is a factor in causing CP, and that it is impossible for a physician to commit malpractice in such a manner as to deprive a fetus of oxygen? None?

Here’s the thing, it’s the facts of the individual case that matter, and you’ll find no single peer reviewed study that will say that malpractice cannot result in CP, either.

” I am not saying it’s right but when a JD wheels in a CP child, he is not using the “science” card or the “best evidence” card, rather the “heartstring” card.”

Would you prefer we have trials without ever seeing the plaintiff? If you’re hit by a car today, and lose the use of a leg, does how you look and the visual effects of that driver’s negligence have no relevance? Are you ethically bankrupt for wanting the jury to see that?

Anonymous

“Are you ethically bankrupt for wanting the jury to see that?”

It’s more like – are you financially bankrupt because you want the jury to see that?

Elliott

Somebody please find a shred of evidence that a C-section reduces either the risk of being sued for malpractice or the risk of losing a malpractice case. I am seriously looking for any previous studies. Most studies that I have been able to find tend to point in the other direction. Doctors sued for malpractice tend to have higher C-section rates (many possible explanations which the data does not determine). Areas with higher malpractice insurance rates tend to have greater C-section rates but the direction of the causality is not available (higher levels of C-section => more malpractice lawsuits => higher rates OR more malpractice lawsuits => higher rates => more C-sections).

The most likely explanation in the absence of any data seems to me to be the economic incentive in doing a C-section. Comparing the two methods of delivery, the treatment through the course of the pregnancy is likely to be the same. The treatment at the end of the pregnancy may require more time doing the procedure, but much less time waiting (many studies show that C-section rates rise as the weekend approaches). It is a no-brainer from an economic perspective. Allow yourself as a doctor to convince yourself that it’s not about money, but a legitimate fear of being sued and the decision becomes even easier.